presentation lbp umi

7/28/2019 Presentation LBP UMI

1/47

DISEASE OF SPINE

LUHU A. TAPIHERU


2/47

Topik

LBP HNP, Lumbar spinal stenosis

Spondilitis TB


3/47

LBP (Low Back Pain)

Life time prevalence 59%

10% leads to consultation to GP

90% improved in 1 month

up to 70% patient tend to recur

EPIDEMIOLOGY


4/47

Non-specific mechanical back pain Facet joint syndrome

Lumbar disc degeneration (lumbar spondylosis)

Lumbar disc prolapse

Spondylolisthesis

Spinal stenosis

Osteoporosis

Sero-negative spondyl arthritis (includingankylosing spondylitis)

Vertebral infection Disc space infection

Malignancy secondary myeloma and primary

Pagets disease, referred-visceral,pancreatic/pelvic, etc

Etiology


5/47

RED FLAGS (possible serious spinal pathology)

Age of onset : < 20 or 55 years

Violent trauma, eg fall from a height, traffic

accident

Constant, progressive, non-mechanical pain

Thoracic pain

History of carcinoma Systemic steroids

Drug abuse, HIV infection

Systemically unwell

Weight loss Persistent severe restriction of lumbar flexion

Widespread neurological deficit

Structural deformity


6/47

1. Mechanical (deformity, trauma)

2. Inflammation

3. Neoplasm

4. Degenerative

5. Psychological

COMMON ETIOLOGY


7/47

Ligamentous Strain

Muscle strain or spasm

Facet join disruption or degeneration

Intervertebral disc degeneration or herniation Vertebral compression fracture

Vertebral end-plate microfractures

Spondylolisthesis

Spinal stenosis Diffuse idiopathic skeletal hyperostosis

MECHANICAL


8/47

SPONDYLOSIS, SPONDYLOLISIS AND

SPONDYLOLISTHESIS

SPONDYLOSIS :

refers to osteoarthritis involving the articular

surfaces (joints and discs) of the spine, often with

osteophyte formation and cord or root compression

SPONDYLOLISIS :

refers to a separation at the pars articularis, which

permits the vertebrae to slip. Maybe uni or bilateral


9/47

SPONDYLOSIS, SPONDYLOLISIS AND

SPONDYLOLISTHESIS

SPONDYLOLISTHESIS :

May result from bilateral pars defects or

degenerative disc disease.

Defined as the anterior subluxation of thesuprajacent vertebrae, often producing central canal

stenosis : it is the slipping forward of one vertebrae

on the vertebrae below.


10/47

Epidural abcess

Vertebral osteomyelitis

Septic discitis

Potts disease (tuberculosis)

Nonspecific manifestation of systemic illness

INFECTION


11/47

Epidural or vertebral carcinomatous

metastases Multiple myeloma

Lymphoma

NEOPLASM


12/47


13/47

HNP


14/47

HNP

HNP : Hernia Nukleus Pulposus

Sinonim : Ruptured disk, prolapsed disk, herniadiskus intervetrebralis

Penyebab NPB (Nyeri punggung bawah) / LBP(low back pain) yang penting

Prevalensi 1 2% dari populasi

90%diskus intervetebralis L5 S1 aan L4

L5 Biasanya membaik 6 minggu


15/47

HNP

Definisi :

Suatu keadaan dimana sebagian atauseluruh bagian nukleus pulposus mengalami

penonjolan ke dalam kanalis spinalis

HNP :

HNP servikalis HNP lumbalis

HNP torakalis


16/47

The disc


17/47

Herniated disc


18/47

Patofisiologi

Diskus intervetebralis penyangga beban(Shock absorber)

Terdiri dua bagian utama :

1. Anulus fibrosus : lapisan luar fibro-kolagenyang saling menyilang, bagian dalam lapisan

fibro-kartilagenus

2. Nukleus pulposus : terdiri dari proteoglycan

yang terdiri dari 80% air (higroskopis)


19/47

HNP Lumbalis

1. L5 S1 tugas berat menyangga berat badan (75%)

2. Mobilitas tinggi pada fleksi dan ekstensi. 57%aktivitas fleksi dan ekstensi dilakukan sendi

L5 - S13. Daerah rawanligamentum longitudinalis

posterior hanya separuh menutupi permukaanposterior diskus arah herniasi postero lateral


20/47

Derajat HNP

Protruded disk: penonjolan nukleus pulposus tanpa

kerusakan annulus fibrosus

Prolapsed disk: nukleus berpindah tetapi tetap

dalam lingkaran annulus fibrosus.

Extruded disk: nukleus keluar dari annulus fibrosus

dan berada di bawah ligamentum longitudinalis

posterior.

Sequestrated dis k: nukleus telah menembus

ligamentum longitudinalis posterior.


21/47

Grade of herniated disc


22/47

Clinical symptoms

Lumbar HNP :

radicular pain

abnormal vertebral posture

paresthesia, parese, diminished tendon reflexes Cervical HNP :

radicular pain, aggravated by neck extension,

and reduced by abducting the arm and put it

behind the head

paresthesia, parese, diminished tendon reflexes


23/47

Ischialgia (sciatic)


24/47

Diagnosis

Anamnesis

Neurological examination Sensorik, motorik, reflek

Lumbar HNP : Lasegue (SLR = straight leg raising) test

Lasegue + provokasi Bragard

Crossed Laseque (crossed SLR) test

Femoral stretch (reverse SLR) test Cervical HNP :

Lhermitte test

Valsava test

Shoulder abduction test


25/47

Diagnosis

Pemeriksaan radiologis : Plain vertebral x-rays :

limited information

disc narrowing, scoliosis, lordosis lumbal

Myelography

CT or CT-myelography

MRI

EMG/NCV : 90% abnormal after 1-2 weeks


26/47

Therapy

CONSERVATIVE bed rest

analgetic, muscle relaxant, ajuvant analgentics

orthopaedic mattress

pelvic traction (controversial)

lumbar corset

OPERATIVE

Indication :1. Fail conservative treatment

2. Progressive motor dysfunction

3. Recurrence

4. Compression of cauda equina

5. Bowel disorders


27/47

Sebagian besar membaik dalam 6 minggu

Sebagian kecil kronik Post Op 90% membaik, rekurensi 5%

Prognosis


28/47

Spinal stenosis


29/47

Lumbar spinal stenosis

CLINICAL SYMPTOMS :

neurogenic intermittent claudiation or

pseudoclaudication (most frequent)

usually bilateral, but maybe unilateral a dull, aching pain

the whole lower extremity is generally affected

pain provoked by walking and standing, quickly

relieved by sitting or leaning forward LBP presents in 65% patients with lumbar spinal

stenosis

radicular pain is the least common manifestation


30/47


31/47

Most frequent causes of spinal stenosis

> 25 causes are identified

The most common :

1. Idiopathic : the result of shorter than normal

pedicles, thickened convergent lamina, and a

convex posterior vertebral body.

2. Degenerative (50% of cases) : degenerative

changes affect the facets posteriorly allowing

instability and subluxation, osteophytes form

and narrow the nerve root and the central canal; and the disc anteriorly allowing the disc to

bulge into the nerve root and central canal.


32/47

most frequent causes of spinal stenosis

3. Degenerative spondylolisthesis : occurs whenthe facets degenerate, allowing slippage of theupper vertebrae forward over the lowervertebrae.

4. Postoperative : occurs after laminectomy orspinal fusion. Stenosis is produced by boneformation and scar tissue


33/47

Indication for surgical treatment of

lumbar spinal stenosis

1. Persistent intolerable pain

2. Limitation of walking distance or standing

endurance to a degree that compromises necessary

activities

3. Severe or progressive muscle weakness or

disturbed bladder of sexual function.


34/47

Spondilitis TB


35/47

Spondilitis TB

Spondilitis TB, s inon im :

Tuberkulosis spinal

Potts disease

Tubercu losis vertebral os teomyel i t is

Mr. Pervical Pott (1779)

Insiden berhubfasilitas pelayanankesehatan dan keadaan sosial


36/47

Epidemiologi Spondilitis TB

Di Asia 50% usia 1 20 tahun Keterlibatan tulang sendi pada pasien TB

10% 50 % mengenai vertebra (Vt thorakal 9 - 10),

sisanya tulang panggul, lutut dan tulang kaki

lainnya

Penyebab paling sering paraplegia non

traumatik


37/47

Patogenesis spondilitis TB

Penyebaran spondilitis TB Hematogen

Langsung nodus limfatikus para aorta dan jalurlimfatikus

Sumber infeksi sistema pulmoner dangenitourinarius

Penyebaran melalui : arteri interkostal / lumbar suplai darah ke dua

vertebrae yang berdekatan (setengah bagianbawah vertebra diatasnya dan bagian atasvertebra di bawahnya)


38/47

pleksus Batsonsmengelilingi columnavertebralismenyebabkan banyak vertebra yangterkena

Tiga bentuk spondilitis TB (lokasi infeksi

pada korpus)

Paradiskal

Sentral

Anterior : adanya scal loped =bentuk baji(erosinya bagian anterior beberapa vertebra)

Atipikal

Patogenesis spondilitis TB


39/47


40/47

Gambaran klinis spondilitis TB

Potts paraplegia

Early onset : < 2 tahun

Late onset : 2 tahun

Paraplegia : Akibat tekanan eksternal (pd med. Spinalis dan

duramater)

Invasi duramater (tdp gambaran meningomielitis

TB / araknoiditis TB) Disertai inkontinesia urin dan alvi, gangguan

sensoris


41/47

Diagnosis spondilitis TB

Anamnesis :

Kehilangan BB, riw. batuk lama, keringat malam

hari, demam intermiten, cachexia

Nyeri : lesi torakal atas

nyeri dada interkostal,lesi torakal bawahnyeri penjalaran ke perut Punggung kaku

Pemeriksaan fisik:

Deformitas : kifosis, gibbus, skoliosis, subluksasi,spondilolisthesis dan dislokasi

Paraparesis UMN, spastisitas,


42/47


43/47


44/47

Lama pemberian ; Menurut Gilroy :

Initial treatment (2 bln) : R, INH, PZA

Continued treatment (9 bln) : R, INH

Menurut Pengobatan TB paru, terbagi 2 fase

1. Fase intensif (2-3 bulan)

2. Fase lanjutan (4-7 bulan)

3. Istirahat tirah baring

Manajemen terapi spondilitis TB


45/47

Indikasi operatif Diagnosa yang meragukan hingga diperlukan untuk

melakukan biopsi

Terdapat instabilitas setelah proses penyembuhan

Terdapat abses yang dapat dengan mudahdidrainase

Untuk penyakit yang lanjut dengan kerusakantulang yang nyata danmengancam atau kifosis

berat saat ini Penyakit yang rekuren

Manajemen terapi spondilitis TB


46/47

1. Mortalitas menurun sejak ditemukannyakemoterapi TB

2. Relaps 0% (pengawasan ketat pemberian regimen)

3. Kifosis deformitas, masalah kosmetik4. Defisit neurologis membaik (tu. Operasi dini)5. Usia dini prognosis lebih baik6. Fusi tulanghal yang penting untuk pemulihan

Prognosis spondilitis TB


47/47

presentation lbp umi

Documents